Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

99402 PREVENTIVE MEDICINE COUNSELING, TYPICALLY 30 MINUTES

Facility

$87.00

Service Code	CPT 99402
Hospital Charge Code	28256447
Hospital Revenue Code	521
Min. Negotiated Rate	$78.30
Max. Negotiated Rate	$78.30
Rate for Payer: Aetna of AZ Commercial	$78.30
Rate for Payer: Cash Price	$69.60

99402 PREVENTIVE MEDICINE COUNSELING, TYPICALLY 30 MINUTES

Facility

$87.00

Service Code	CPT 99402
Hospital Charge Code	28256447
Hospital Revenue Code	521
Min. Negotiated Rate	$13.13
Max. Negotiated Rate	$78.30
Rate for Payer: Aetna of AZ Commercial	$78.30
Rate for Payer: Arizona Complete Health Allwell	$13.92
Rate for Payer: Banner UC Health Medicare	$13.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$59.16
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13.13
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.92
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cigna of AZ Commercial	$60.90
Rate for Payer: Devoted Health Medicare	$15.66
Rate for Payer: Humana of AZ Medicare	$13.92
Rate for Payer: Mercy Care Medicaid	$13.13
Rate for Payer: NaphCare Correctional Healthcare	$13.13
Rate for Payer: Southwest Service Administrators UFCW	$59.16
Rate for Payer: TriWest Medicare	$13.92
Rate for Payer: United Healthcare Commercial	$49.76
Rate for Payer: United Healthcare Medicare	$13.92
Rate for Payer: Veterans Affairs TRICARE	$13.78

99403 PREVENTIVE MEDICINE COUNSELING, TYPICALLY 45 MINUTES

Facility

$130.00

Service Code	CPT 99403
Hospital Charge Code	28255422
Hospital Revenue Code	521
Min. Negotiated Rate	$13.13
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna of AZ Commercial	$117.00
Rate for Payer: Arizona Complete Health Allwell	$20.80
Rate for Payer: Banner UC Health Medicare	$20.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$88.40
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13.13
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.80
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cigna of AZ Commercial	$91.00
Rate for Payer: Devoted Health Medicare	$23.40
Rate for Payer: Humana of AZ Medicare	$20.80
Rate for Payer: Mercy Care Medicaid	$13.13
Rate for Payer: NaphCare Correctional Healthcare	$13.13
Rate for Payer: Southwest Service Administrators UFCW	$88.40
Rate for Payer: TriWest Medicare	$20.80
Rate for Payer: United Healthcare Commercial	$74.36
Rate for Payer: United Healthcare Medicare	$20.80
Rate for Payer: Veterans Affairs TRICARE	$20.59

99403 PREVENTIVE MEDICINE COUNSELING, TYPICALLY 45 MINUTES

Facility

$130.00

Service Code	CPT 99403
Hospital Charge Code	28255422
Hospital Revenue Code	521
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna of AZ Commercial	$117.00
Rate for Payer: Cash Price	$104.00

99404 PREVENTIVE MEDICINE COUNSELING, TYPICALLY 1 HOUR

Facility

$173.00

Service Code	CPT 99404
Hospital Charge Code	28254125
Hospital Revenue Code	521
Min. Negotiated Rate	$13.13
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna of AZ Commercial	$155.70
Rate for Payer: Arizona Complete Health Allwell	$27.68
Rate for Payer: Banner UC Health Medicare	$27.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$117.64
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13.13
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.68
Rate for Payer: Cash Price	$138.40
Rate for Payer: Cash Price	$138.40
Rate for Payer: Cigna of AZ Commercial	$121.10
Rate for Payer: Devoted Health Medicare	$31.14
Rate for Payer: Humana of AZ Medicare	$27.68
Rate for Payer: Mercy Care Medicaid	$13.13
Rate for Payer: NaphCare Correctional Healthcare	$13.13
Rate for Payer: Southwest Service Administrators UFCW	$117.64
Rate for Payer: TriWest Medicare	$27.68
Rate for Payer: United Healthcare Commercial	$98.96
Rate for Payer: United Healthcare Medicare	$27.68
Rate for Payer: Veterans Affairs TRICARE	$27.40

99404 PREVENTIVE MEDICINE COUNSELING, TYPICALLY 1 HOUR

Facility

$173.00

Service Code	CPT 99404
Hospital Charge Code	28254125
Hospital Revenue Code	521
Min. Negotiated Rate	$155.70
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna of AZ Commercial	$155.70
Rate for Payer: Cash Price	$138.40

99420 Health risk assessment test

Facility

$28.00

Service Code	CPT 99420
Hospital Charge Code	22245602
Hospital Revenue Code	521
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$25.20
Rate for Payer: Aetna of AZ Commercial	$25.20
Rate for Payer: Cash Price	$22.40

99420 Health risk assessment test

Facility

$28.00

Service Code	CPT 99420
Hospital Charge Code	22245602
Hospital Revenue Code	521
Min. Negotiated Rate	$4.44
Max. Negotiated Rate	$25.20
Rate for Payer: Aetna of AZ Commercial	$25.20
Rate for Payer: Arizona Complete Health Allwell	$4.48
Rate for Payer: Banner UC Health Medicare	$4.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$19.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.48
Rate for Payer: Cash Price	$22.40
Rate for Payer: Cigna of AZ Commercial	$19.60
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Humana of AZ Medicare	$4.48
Rate for Payer: Southwest Service Administrators UFCW	$19.04
Rate for Payer: TriWest Medicare	$4.48
Rate for Payer: United Healthcare Commercial	$16.02
Rate for Payer: United Healthcare Medicare	$4.48
Rate for Payer: Veterans Affairs TRICARE	$4.44

99422 ONLINE DIGITAL EVALUATION AND MANAGEMENT SERVICE FOR A

Facility

$55.00

Service Code	CPT 99422
Hospital Charge Code	28254124
Hospital Revenue Code	521
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$49.50
Rate for Payer: Aetna of AZ Commercial	$49.50
Rate for Payer: Arizona Complete Health Allwell	$8.80
Rate for Payer: Banner UC Health Medicare	$8.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$37.40
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$4.65
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.80
Rate for Payer: Cash Price	$44.00
Rate for Payer: Cash Price	$44.00
Rate for Payer: Cigna of AZ Commercial	$38.50
Rate for Payer: Devoted Health Medicare	$9.90
Rate for Payer: Humana of AZ Medicare	$8.80
Rate for Payer: Mercy Care Medicaid	$4.65
Rate for Payer: NaphCare Correctional Healthcare	$4.65
Rate for Payer: Southwest Service Administrators UFCW	$37.40
Rate for Payer: TriWest Medicare	$8.80
Rate for Payer: United Healthcare Commercial	$31.46
Rate for Payer: United Healthcare Medicare	$8.80
Rate for Payer: Veterans Affairs TRICARE	$8.71

99422 ONLINE DIGITAL EVALUATION AND MANAGEMENT SERVICE FOR A

Facility

$55.00

Service Code	CPT 99422
Hospital Charge Code	28254124
Hospital Revenue Code	521
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$49.50
Rate for Payer: Aetna of AZ Commercial	$49.50
Rate for Payer: Cash Price	$44.00

99443 TELEPHONE EVALUATION AND MANAGEMENT SERVICE BY A PHYSI

Facility

$398.00

Service Code	CPT 99443
Hospital Charge Code	23919287
Hospital Revenue Code	521
Min. Negotiated Rate	$63.04
Max. Negotiated Rate	$358.20
Rate for Payer: Aetna of AZ Commercial	$358.20
Rate for Payer: Arizona Complete Health Allwell	$63.68
Rate for Payer: Banner UC Health Medicare	$63.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$270.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$63.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$63.68
Rate for Payer: Cash Price	$318.40
Rate for Payer: Cigna of AZ Commercial	$278.60
Rate for Payer: Devoted Health Medicare	$71.64
Rate for Payer: Humana of AZ Medicare	$63.68
Rate for Payer: Southwest Service Administrators UFCW	$270.64
Rate for Payer: TriWest Medicare	$63.68
Rate for Payer: United Healthcare Commercial	$227.66
Rate for Payer: United Healthcare Medicare	$63.68
Rate for Payer: Veterans Affairs TRICARE	$63.04

99443 TELEPHONE EVALUATION AND MANAGEMENT SERVICE BY A PHYSI

Facility

$398.00

Service Code	CPT 99443
Hospital Charge Code	23919287
Hospital Revenue Code	521
Min. Negotiated Rate	$358.20
Max. Negotiated Rate	$358.20
Rate for Payer: Aetna of AZ Commercial	$358.20
Rate for Payer: Cash Price	$318.40

99455 CDL Physical

Facility

$160.00

Service Code	CPT 99455
Hospital Charge Code	22245603
Hospital Revenue Code	983
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna of AZ Commercial	$144.00
Rate for Payer: Arizona Complete Health Allwell	$25.60
Rate for Payer: Banner UC Health Medicare	$25.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$108.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$25.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$25.60
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cigna of AZ Commercial	$112.00
Rate for Payer: Devoted Health Medicare	$28.80
Rate for Payer: Humana of AZ Medicare	$25.60
Rate for Payer: Southwest Service Administrators UFCW	$108.80
Rate for Payer: TriWest Medicare	$25.60
Rate for Payer: United Healthcare Commercial	$91.52
Rate for Payer: United Healthcare Medicare	$25.60
Rate for Payer: United Healthcare New Mexico Commercial	$30.40
Rate for Payer: Veterans Affairs TRICARE	$25.34

99455 CDL Physical

Facility

$160.00

Service Code	CPT 99455
Hospital Charge Code	22245603
Hospital Revenue Code	983
Min. Negotiated Rate	$144.00
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna of AZ Commercial	$144.00
Rate for Payer: Cash Price	$128.00

99455SP Sports Physical

Facility

$25.00

Service Code	CPT 99455
Hospital Charge Code	22245604
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of AZ Commercial	$22.50
Rate for Payer: Cash Price	$20.00

99455SP Sports Physical

Facility

$25.00

Service Code	CPT 99455
Hospital Charge Code	22245604
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of AZ Commercial	$22.50
Rate for Payer: Arizona Complete Health Allwell	$4.00
Rate for Payer: Banner UC Health Medicare	$4.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$17.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cigna of AZ Commercial	$17.50
Rate for Payer: Devoted Health Medicare	$4.50
Rate for Payer: Humana of AZ Medicare	$4.00
Rate for Payer: Southwest Service Administrators UFCW	$17.00
Rate for Payer: TriWest Medicare	$4.00
Rate for Payer: United Healthcare Commercial	$14.30
Rate for Payer: United Healthcare Medicare	$4.00
Rate for Payer: Veterans Affairs TRICARE	$3.96

99473 Self-Meas BP Pt Educ/Train

Facility

$16.00

Service Code	CPT 99473
Hospital Charge Code	24091375
Hospital Revenue Code	521
Min. Negotiated Rate	$2.53
Max. Negotiated Rate	$44.75
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Arizona Complete Health Allwell	$2.56
Rate for Payer: Banner UC Health Medicare	$2.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$10.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.56
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cigna of AZ Commercial	$11.20
Rate for Payer: Devoted Health Medicare	$2.88
Rate for Payer: Humana of AZ Medicare	$2.56
Rate for Payer: Seven Corners Travel Insurance	$44.75
Rate for Payer: Southwest Service Administrators UFCW	$10.88
Rate for Payer: TriWest Medicare	$2.56
Rate for Payer: United Healthcare Commercial	$9.15
Rate for Payer: United Healthcare Medicare	$2.56
Rate for Payer: Veterans Affairs TRICARE	$2.53

99473 Self-Meas BP Pt Educ/Train

Facility

$16.00

Service Code	CPT 99473
Hospital Charge Code	24091375
Hospital Revenue Code	521
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Cash Price	$12.80

99474 Self-Meas BP 2 reading BID 30D

Facility

$21.00

Service Code	CPT 99474
Hospital Charge Code	24091391
Hospital Revenue Code	521
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Cash Price	$16.80

99474 Self-Meas BP 2 reading BID 30D

Facility

$21.00

Service Code	CPT 99474
Hospital Charge Code	24091391
Hospital Revenue Code	521
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Arizona Complete Health Allwell	$3.36
Rate for Payer: Banner UC Health Medicare	$3.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.28
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8.22
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.36
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna of AZ Commercial	$14.70
Rate for Payer: Devoted Health Medicare	$3.78
Rate for Payer: Humana of AZ Medicare	$3.36
Rate for Payer: Mercy Care Medicaid	$8.22
Rate for Payer: NaphCare Correctional Healthcare	$8.22
Rate for Payer: Southwest Service Administrators UFCW	$14.28
Rate for Payer: TriWest Medicare	$3.36
Rate for Payer: United Healthcare Commercial	$12.01
Rate for Payer: United Healthcare Medicare	$3.36
Rate for Payer: Veterans Affairs TRICARE	$3.33

A4550 Surgical Binders Charge

Facility

$130.00

Service Code	HCPCS A4550
Hospital Charge Code	795179
Hospital Revenue Code	521
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna of AZ Commercial	$117.00
Rate for Payer: Cash Price	$104.00

A4550 Surgical Binders Charge

Facility

$130.00

Service Code	HCPCS A4550
Hospital Charge Code	795179
Hospital Revenue Code	521
Min. Negotiated Rate	$20.59
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna of AZ Commercial	$117.00
Rate for Payer: Arizona Complete Health Allwell	$20.80
Rate for Payer: Banner UC Health Medicare	$20.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$88.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.80
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cigna of AZ Commercial	$91.00
Rate for Payer: Devoted Health Medicare	$23.40
Rate for Payer: Humana of AZ Medicare	$20.80
Rate for Payer: Southwest Service Administrators UFCW	$88.40
Rate for Payer: TriWest Medicare	$20.80
Rate for Payer: United Healthcare Commercial	$74.36
Rate for Payer: United Healthcare Medicare	$20.80
Rate for Payer: Veterans Affairs TRICARE	$20.59

A6441 Padding bandage, width >=3<5 in, per yard

Facility

$17.00

Service Code	HCPCS A6441
Hospital Charge Code	22281177
Hospital Revenue Code	521
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$15.30
Rate for Payer: Aetna of AZ Commercial	$15.30
Rate for Payer: Cash Price	$13.60

A6441 Padding bandage, width >=3<5 in, per yard

Facility

$17.00

Service Code	HCPCS A6441
Hospital Charge Code	22281177
Hospital Revenue Code	521
Min. Negotiated Rate	$2.69
Max. Negotiated Rate	$15.30
Rate for Payer: Aetna of AZ Commercial	$15.30
Rate for Payer: Arizona Complete Health Allwell	$2.72
Rate for Payer: Banner UC Health Medicare	$2.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$11.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.72
Rate for Payer: Cash Price	$13.60
Rate for Payer: Cigna of AZ Commercial	$11.90
Rate for Payer: Devoted Health Medicare	$3.06
Rate for Payer: Humana of AZ Medicare	$2.72
Rate for Payer: Southwest Service Administrators UFCW	$11.56
Rate for Payer: TriWest Medicare	$2.72
Rate for Payer: United Healthcare Commercial	$9.72
Rate for Payer: United Healthcare Medicare	$2.72
Rate for Payer: Veterans Affairs TRICARE	$2.69

abatacept 250 mg REC [CQCH]

Facility

$1,338.50

Service Code	HCPCS J0129
Hospital Charge Code	220821185
Hospital Revenue Code	250
Min. Negotiated Rate	$1,204.65
Max. Negotiated Rate	$1,204.65
Rate for Payer: Aetna of AZ Commercial	$1,204.65
Rate for Payer: Cash Price	$1,070.80

Know your out-of-pocket cost for care.

All Charges